A cluster-randomized trial to reduce major perinatal morbidity among women with one prior cesarean delivery in Québec (PRISMA trial): study protocol for a randomized controlled trial.

BACKGROUND: Rates of cesarean delivery are continuously increasing in industrialized countries, with repeated cesarean accounting for about a third of all cesareans. Women who have undergone a first cesarean are facing a difficult choice for their next pregnancy, i.e.: (1) to plan for a second cesarean delivery, associated with higher risk of maternal complications than vaginal delivery; or (b) to have a trial of labor (TOL) with the aim to achieve a vaginal birth after cesarean (VBAC) and to accept a significant, but rare, risk of uterine rupture and its related maternal and neonatal complications. The objective of this trial is to assess whether a multifaceted intervention would reduce the rate of major perinatal morbidity among women with one prior cesarean. METHODS/DESIGN: The study is a stratified, non-blinded, cluster-randomized, parallel-group trial of a multifaceted intervention. Hospitals in Quebec are the units of randomization and women are the units of analysis. As depicted in Figure 1, the study includes a 1-year pre-intervention period (baseline), a 5-month implementation period, and a 2-year intervention period. At the end of the baseline period, 20 hospitals will be allocated to the intervention group and 20 to the control group, using a randomization stratified by level of care. Medical records will be used to collect data before and during the intervention period. Primary outcome is the rate of a composite of major perinatal morbidities measured during the intervention period. Secondary outcomes include major and minor maternal morbidity; minor perinatal morbidity; and TOL and VBAC rate. The effect of the intervention will be assessed using the multivariable generalized-estimating-equations extension of logistic regression. The evaluation will include subgroup analyses for preterm and term birth, and a cost-effectiveness analysis. DISCUSSION: The intervention is designed to facilitate: (1) women's decision-making process, using a decision analysis tool (DAT), (2) an estimate of uterine rupture risk during TOL using ultrasound evaluation of low-uterine segment thickness, (3) an estimate of chance of TOL success, using a validated prediction tool, and (4) the implementation of best practices for intrapartum management. TRIAL REGISTRATION: Current Controlled Trials, ID: ISRCTN15346559 . Registered on 20 August 2015.

Contrasting phenotypes of C57BL/6JOlaHsd, 129S2/SvHsd and 129/SvEv mice in two exploration-based tests of anxiety-related behaviour.

Knockout mice are typically generated on a mixed genetic background and, as such, detailed behavioural characterisation of these background strains is essential to the valid interpretation of mutant phenotypes. In this context, recent research has revealed significant differences in anxiety-like behaviour among the most commonly used background strains (C57BL/6J and various 129 substrains), leading to the possibility that at least certain mutant phenotypes may not after all be due to the targeted mutation. However, these findings derive largely from behavioural test batteries in which there may well be an experiential confound, while the widely reported hypolocomotor profile of most 129 substrains may compromise the principal indices of anxiety-like behaviour. In the present study, we have compared the behavioural profiles of three commonly used background strains (C57BL/6JOlaHsd, 129/SvEv and 129S2/SvHsd) in two of the most popular animal models of anxiety-the elevated plus-maze (EPM) and light/dark exploration (LDE) tests. Naive animals were used for each procedure, ethological scoring methods were employed throughout, and the inbred phenotypes were also compared with that of an outbred strain (Swiss-Webster) widely employed in test validation and behavioural pharmacology. Our results show that, despite their hypolocomotor profile, both 129 substrains display higher levels of anxiety-like behaviour (conventional and/or ethological measures) relative to the C57BL/6JOlaHsd strain. Furthermore, all three inbred strains were less active in both tests when compared with the outbred Swiss-Webster strain. However, whereas C57BL/6JOlaHsd mice displayed lower levels of anxiety-like behaviour than their Swiss-Webster counterparts (both tests), 129S2/SvHsd (but not 129/SvEv) mice exhibited evidence of higher anxiety, particularly in the LDE test. The implications of these findings are discussed in relation to both the behavioural and pharmacological phenotyping of mutant mice.

Developing information literacy: a key to evidence-based nursing.

This report describes the evaluation of a curriculum-integrated programme designed to help students develop an awareness of the nursing literature, the skills to locate and retrieve it, and skills required in its evaluation; in other words'information literacy'. Positive changes in student performance on objective measures of information-literacy skills were revealed as well as a significant increase in the levels of confidence of the student in performing those skills. Students who had undertaken the information-literacy programme ('programme' students) performed better on a range of objective measures of information literacy, as well as reporting higher levels of confidence in these skills, than students who had not participated in the programme ('non-programme' students). Evaluation of this programme provides evidence of the potential usefulness of a curriculum-integrated approach for the development of information-literacy skills within nursing education. With these underlying skills, students will be better equipped to consolidate and extend their key information-literacy skills to include research appreciation and application. These are vital for effective lifelong learning and a prerequisite to evidence-based practice.

Women's choice? The impact of private health insurance on episiotomy rates in Australian hospitals.

OBJECTIVE: To assess the extent to which variations in episiotomy rates in Australian hospitals are justified by clinical variables and to further explore the relationships between episiotomy, insurance status, perineal trauma and outcomes for babies. DESIGN: A retrospective analysis of anonymous medical record data using logistic regression models, aimed at identifying factors influencing both episiotomy rates and outcomes for babies. SETTING: A large regional public hospital, New South Wales, Australia. PARTICIPANTS: The study sample consisted of 2028 women who delivered vaginally during a 12 month period during 1996-1997. RESULTS: After controlling for clinical and other factors privately insured women were estimated to be up to twice as likely to experience episiotomy as publicly insured women. This difference most plausibly reflects differences in labour management styles between obstetricians and midwives. Other significant contributors to episiotomy were instrumental delivery, indications of possible fetal distress and lower parity. Severe perineal trauma (third degree tear) was found to be positively associated with episiotomy. Furthermore, the incidence of additional tears requiring suture was also substantially higher among privately insured women, the net effect being that these women had a substantially lower chance of achieving an intact perineum. Neither episiotomy nor insurance status had any significant effect on the well-being of babies. IMPLICATIONS FOR PRACTICE: Private health insurance appears to deny many women the opportunity of achieving normal vaginal delivery with intact perineum. Episiotomy rates amongst privately insured women in Australia may be higher than is clinically appropriate, and severe perineal trauma within this study was associated with this practice.

Teaching information literacy skills: an evaluation.

This paper describes an evaluation of a curriculum-integrated information literacy programme in an undergraduate nursing course. The aim of the programme was to provide students with an awareness of the discipline's literature and the skills to locate and retrieve the literature. A multidimensional process for determining nursing students' development was utilised in the evaluation of the programme. Pre- and post-programme questionnaires were distributed to a cohort of students who undertook the programme. A cohort of more senior students who had not undertaken the information literacy programme was utilised as a comparison group. Questionnaire results were analysed using a range of inferential statistics. This paper will focus on two main findings related to objective measures of information literacy skills. These include pre-programme/post-programme change in student performance and differences in student performance between those who undertook the programme and those who did not. The programme demonstrated its effectiveness in developing information literacy skills, however the challenge remains for both academics and students to ensure that these skills are consolidated and extended for effective life-long learning.

Episiotomy in NSW hospitals 1993-1996: towards understanding variations between public and private hospitals.

Episiotomy rates for women experiencing childbirth in New South Wales (NSW) hospitals are another indicator that private insurance may be a risk factor for obstetric intervention. A recent comparison of episiotomy rates in NSW public and private hospitals between 1993 and 1996 revealed that episiotomy rates were 12 to 15 percentage points higher in NSW private hospitals than in public hospitals studied. Rates also appear to be declining in NSW public hospitals, yet this trend is not evident in the NSW private hospitals studied. Although private hospital patients were almost twice as likely to experience forceps or vacuum delivery (often associated with episiotomy), this leaves a 6 to 8 percentage point difference unexplained. Given the potential health-related quality of life issues associated with perineal trauma during childbirth, further analysis of the clinical make-up of privately insured women may help determine the extent to which clinical explanations exist to support the differences in this childbirth intervention.

Integrating information literacies into an undergraduate nursing programme.

The development of support for a more research-based approach to care has created the imperative for nursing education to tackle the issue of information literacy. Information literacy means the ability to locate, evaluate and apply information in critical thinking and problem solving. This paper outlines and provides a rationale for a curriculum-integrated information literacy programme, implemented in the pre-registration Bachelor of Nursing course at the University of Wollongong, NSW, Australia. It also describes a multidimensional evaluation process for determining nursing students' growth in cognitive and affective domains. Results of the programme evaluation will be featured in a future paper.

Trial of labour versus elective repeat caesarean section: a cost-effectiveness analysis.

For subsequent births, women who have experienced previous caesarean section face a choice between elective caesarean section and trial of labour. The study reported in this paper utilises Australian hospital data to compare birth outcome and health system costs of these two options. Although trial of labour is more expensive if the result is an emergency caesarean section, high rates of successful vaginal delivery mean that, overall, trial of labour is found to be 30 per cent less expensive than elective caesarean section. It is estimated that trial of labour remains the most cost-effective option as long as less than 68 per cent of women require emergency caesarean section. This study highlights the potential importance of more accurate information about a broader range of costs and outcomes in order for stronger conclusions to be drawn.

Paving the way: stepping stones to evidence-based nursing.

Evidence-based practice is an emerging paradigm in health care. This paper outlines the main features of this paradigm and its potential value to nursing. Evidence-based practice is based on a conceptual framework that examines the extent of evidence available in support of particular clinical practices. The Quality of Evidence Ratings adapted by the National Health and Medical Research Council (NHMRC) from the United States Preventive Services Task Force are discussed, and the strengths and weaknesses of different categories of evidence are highlighted. Potential barriers to implementation of research into practice are identified. The authors suggest that legal, ethical, economic and humane imperatives oblige nursing to develop evidence-based practice as one of several viable contributions to nursing knowledge. Suggestions for analysing current research and for the planning of the direction of future nursing research are made.

Female circumcision: understanding special needs.

The article discusses the provision of appropriate care that is sensitive to the special physical and psychosocial needs of the circumcised client seeking midwifery services in Australia. Aspects addressed include prevalence of the practice globally; potential problems for the prenatal, intrapartum, and postnatal periods; and implications for the midwife caring for the woman during these periods. Appropriate strategies for management include gaining an awareness of individual, cultural, and personal needs; provision of appropriate education in the prenatal and postnatal periods; establishment of positive working relationships with the family as a whole; and provision of adequate pain relief at all times. Health care policy can affect the ability of midwives and other health professionals to provide for culturally specific health needs.

Obstetric early discharge versus traditional hospital stay.

Recent research and media reports have suggested that obstetric early discharge is not cost-effective for postnatal care in the Australian health care system, based on the work of the Centre for Health Economic Research and Evaluation. This is probably an erroneous conclusion because the centre excludes the important cost category of medical costs, and its conclusions depend on survey estimates of 'community costs' which are empirically of poor quality and theoretically of doubtful relevance to health care system decision-making. This study finds that obstetric early discharge is more cost-effective than a traditional hospital stay even when community costs are included; and highly cost-effective when considering health system costs alone. Further cost advantages are simulated by increasing obstetric early discharge program activity and reducing length of stay for both programs. Our results suggest that safe, cost-effective options for low-risk obstetric care deserve further investigation in Australia.